Jean-Christophe Allo

High-sensitivity versus conventional troponin in the emergency department for the diagnosis of acute myocardial infarction

IntroductionRecently, newer assays for cardiac troponin (cTn) have been developed which are able to detect changes in concentration of the biomarker at or below the 99th percentile for a normal population. The objective of this study was to compare the diagnostic performance of a new high-sensitivity troponin T (HsTnT) assay to that of conventional cTnI for the diagnosis of acute myocardial infarction (AMI) according to pretest probability (PTP).MethodsIn consecutive patients who presented to our emergency departments with chest pain suggestive of AMI, levels of HsTnT were measured at presentation, blinded to the emergency physicians, who were asked to estimate the empirical PTP of AMI. The discharge diagnosis was adjudicated by two independent experts on the basis of all available data.ResultsA total of 317 patients were included, comprising 149 (47%) who were considered to have low PTP, 109 (34%) who were considered to have moderate PTP and 59 (19%) who were considered to have high PTP. AMI was confirmed in 45 patients (14%), 22 (9%) of whom were considered to have low to moderate PTP and 23 (39%) of whom were considered to have high PTP (P < 0.001). In the low to moderate PTP group, HsTnT levels ≥ 0.014 μg/L identified AMI with a higher sensitivity than cTnI (91%, 95% confidence interval (95% CI) 79 to 100, vs. 77% (95% CI 60 to 95); P = 0.001), but the negative predictive value was not different (99% (95% CI 98 to 100) vs. 98% (95% CI 96 to 100)). There was no difference in area under the receiver operating characteristic (ROC) curve between HsTnT and cTnI (0.93 (95% CI 0.90 to 0.98) vs. 0.94 (95% CI 0.88 to 0.97), respectively).ConclusionsIn patients with low to moderate PTP of AMI, HsTnT is slightly more useful than cTnI. Our results confirm that the use of HsTnT has a higher sensitivity than conventional cTnI.

Copeptin for rapid rule out of acute myocardial infarction in emergency department

BACKGROUND Copeptin, in combination with conventional troponin (cTn), has been suggested as a means of rapid rule out of the diagnosis of acute myocardial infarction (AMI). This study aims to assess the value of copeptin for rule out of AMI, according to the pre-test probability (PTP). METHODS In a prospective multicentric study, we enrolled patients presenting into emergency departments with chest pain <6h, copeptin was measured, and PTP was quoted. The discharge diagnosis was adjudicated by 2 independent experts using all available data, including cTnI. RESULTS 317 patients were included: 148 (46%) had low, 110 (35%) moderate and 59 (19%) high PTP. Final diagnosis was AMI in 45 patients (14%). Median copeptin level was higher in AMI patients compared with that in patients having other diagnoses (23.2 vs. 9.9 pmol/L, p=0.01). A copeptin level ≥10.7 pmol/L in combination with cTnI detected AMI with higher sensitivity than for cTnI alone (98 [87-100] vs. 71 [55-83] %, p=0.001), whatever the PTP. The negative predictive value of the combination copeptin+cTnI was increased, compared to that of cTnI alone (99 [97-100] vs. 95 [92-97] %, p<0.05). CONCLUSIONS In triage of chest pain patients, the additional use of copeptin with conventional cTnI might allow a rapid and reliable rule out of the diagnosis of AMI regardless of the PTP.

Heart-type fatty acid binding protein and the diagnosis of acute coronary syndrome in the ED ☆

BACKGROUND In combination with cardiac troponin, heart-type fatty acid binding protein (h-FABP)-a biomarker of myocardial necrosis-offers the possibility of rapidly eliminating the diagnosis of acute myocardial infarction (AMI). OBJECTIVE The main objective of this study was to assess the incremental value of h-FABP to cardiac troponin for a rapid elimination of AMI, according to the pretest probability (PTP) of AMI. METHODS In consecutive patients presenting to emergency departments (ED) with chest pain less than 6 hours suggestive of AMI, h-FABP levels were measured, blinded to the ED physicians, who were asked to quote the PTP of AMI. The discharge diagnosis was adjudicated by 2 independent experts, blind to the h-FABP level. RESULTS Three hundred seventeen patients (mean age of 57 years) were included in whom 149 had (47%) low, 117 (37%) moderate, and 51 (16%) high PTP. The final diagnosis was AMI in 45 patients (14%), including 16 STEMIs (5%). The negative predictive value for diagnostic elimination of AMI of an h-FABP less than 3 μg/L, combined with a negative cTnI was not higher than that of cardiac troponin I (cTnI) alone (96% [95% confidence interval, 93%-98%] vs 95% [93%-98%]), regardless of the PTP). Even in the low-PTP group, we did not demonstrate a significant improvement in negative predictive value with the addition of h-FABP, compare with that of cTnI alone (100% [97%-100%] vs 99% [96%-100%]). CONCLUSION In triage of patients with chest pain, use of h-FABP does not provide useful additional information to cTnI for excluding the diagnosis of ST-elevation myocardial infarction and non-ST-elevation myocardial infarction diagnosis, whatever the PTP.

B-type natriuretic peptides for the diagnosis of congestive heart failure in dyspneic oldest-old patients.

OBJECTIVES To evaluate the accuracy of B-type natriuretic peptide (BNP) and amino-terminal pro-brain natriuretic peptide (NT-proBNP) for the diagnosis of congestive heart failure (CHF) in dyspneic patients aged >or=85 years admitted to the Emergency Department (ED), and to define threshold values in this oldest-old population. DESIGN AND METHODS This study involved 210 oldest-old patients, and 360 patients aged from 65 to 84 years (<85 years), admitted to the ED for dyspnea. RESULTS Median BNP and NT-proBNP levels were significantly higher in CHF oldest-old patients (p<0.001). BNP and NT-proBNP threshold values were higher in oldest-old patients (290 and 2800 pg/mL, respectively) compared to that of patients <85 years (270 and 1700 pg/mL, respectively). In a multivariate analysis, both BNP and NT-proBNP were the strongest variables associated with CHF in oldest-old patients. Neither renal function nor gender had impact on the diagnostic utility of the two tests. CONCLUSION Both BNP and NT-proBNP could potentially be reliable biomarkers for the diagnosis of CHF in oldest-old patients admitted with acute dyspnea to the ED.

N-Terminal pro B-type natriuretic peptide testing for short-term prognosis in breathless older adults

BACKGROUND Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is useful for the triage of patients with dyspnea. Our aim was to determine whether NT-proBNP levels could predict in-hospital outcome in breathless elderly patients. METHODS At admission, NT-proBNP plasma concentrations were determined in 324 dyspneic patients aged 75 years and older. The association between NT-proBNP values and in-hospital mortality was assessed. RESULTS Median NT-proBNP concentrations were not different in deceased patients (n = 43, 13%) compared to that of survivors (n = 281, 87%) (4354 vs 2499 pg/mL, respectively; P = .06). To predict in-hospital mortality, the optimum threshold of NT-proBNP was 3855 pg/mL, as defined by the receiver operating characteristic (ROC) curve, with a nonsignificant area under the ROC curve of 0.59. Mortality was significantly higher in patients (n = 139) with NT-proBNP levels 3855 pg/mL or higher (17.9% vs 9.7%, P = .045). After multivariate analysis, NT-proBNP level 3855 pg/mL or higher at admission was predictive of mortality (odds ratio, 2.41; 95% confidence interval, 1.02-5.68; P = .04). CONCLUSION NT-proBNP higher than 3855 pg/mL is associated with in-hospital mortality in patients aged 75 years and older admitted for dyspnea.

Accuracy of D-Dimers to Rule Out Venous Thromboembolism Events across Age Categories

Background. Strategies combining pretest clinical assessment and D-dimers measurement efficiently and safely rule out venous thromboembolism events (VTE) in low- and intermediate-risk patients. Objectives. As process of ageing is associated with altered concentrations of coagulation markers including an increase in D-dimers levels, we investigated whether D-dimers could reliably rule out VTE across age categories. Method. We prospectively assessed the test performance in 1,004 patients visiting the emergency department during the 6-month period with low or intermediate risk of VTE who also received additional diagnostic procedures. Results. 67 patients had VTE with D-dimers levels above the threshold, and 3 patients displayed D-dimers levels below the threshold. We observed that specificity of D-dimers test decreased in an age-dependent manner. However, sensitivity and negative predictive value remained at very high level in each age category including older patients. Conclusion. We conclude that, even though D-dimers level could provide numerous false positive results in elderly patients, its high sensitivity could reliably help physicians to exclude the diagnosis of VTE in every low- and intermediate-risk patient.

RETRACTED ARTICLE: Concomitant measurement of copeptin and high-sensitivity troponin for fast and reliable rule out of acute myocardial infarction

Y. Freund ()) B. Riou Service d’Accueil des Urgences, Hôpital Pitié-Salpétrière, Assistance Publique-Hôpitaux de Paris (APHP), Université Pierre et Marie Curie-Paris 6 (UPMC), 47-83 Boulevard de l’Hôpital, 75651 Paris cedex 13, France e-mail: yonathanfreund@gmail.com Tel.: ?33-1-42177912 Fax: ?33-1-42177412 C. Chenevier-Gobeaux Departement de Biochimie, Hôpital Cochin–Hôtel Dieu, APHP, 27 rue du Faubourg Saint-Jacques, 75679 Paris cedex 14, France

Offline exhaled nitric oxide in emergency department and subsequent acute asthma control.

Background. Few studies have evaluated exhaled NO measurement during acute asthma. Objectives. To evaluate exhaled NO fraction (FENO) and peak expiratory flow (PEF) time-courses during acute asthma treatment (β 2-agonist plus systemic steroid) and to assess whether FENO time-course predicts subsequent asthma control. Methods. Sixty-five asthmatic patients (mean ± SD, 34 ± 10 years) were prospectively enrolled in three Emergency Departments. Results. Sixteen patients were excluded (failure of offline FENO measurement at 100 mL/s [FENO 0.1], n = 4, and early discharge). The 49 remaining patients performed FENO 0.1 and PEF on admission, at the 2nd (H2) and 6th hour (H6). Follow-up using an Asthma Control Diary was obtained in 27 of 49 patients, whether they were hospitalized (n = 9) or discharged (n = 18). All but 2 patients had elevated FENO on admission (median [interquartile], 49 [26–78] ppb). Unlike PEF, mean FENO 0.1 of our sample was not significantly modified by treatment. No significant relationship was evidenced between exhaled NO and PEF variations. The variation of FENO 0.1 [H0 minus H6] was different in patients who were hospitalized (decrease of 8 ± 20 ppb) versus discharged (increase of 5 ± 20 ppb, p = 0.04). This variation of FENO 0.1 was correlated with the Diary score (control of subsequent week), an initial increase in FENO 0.1 being associated with better asthma control. Nevertheless, neither exhaled NO nor PEFR were good predictors of asthma control. Conclusions. An increase in FENO is observed in almost all patients with acute asthma, and its subsequent increase within 6 hours is associated with a better degree of asthma control in the subsequent week.

Chilaiditi’s sign or Chilaiditi’s syndrome in the emergency department

A 40-year-old woman presented to our emergency department with an acute 4-hour history of central abdominal pain associated with nausea and vomiting. She had no past medical or surgical history but had undergone a second uncomplicated delivery 15 days previously. Her body mass index was in the normal …

Chilaiditi's sign or Chilaiditi's syndrome in the emergency department.

A 40-year-old woman presented to our emergency department with an acute 4-hour history of central abdominal pain associated with nausea and vomiting. She had no past medical or surgical history but had undergone a second uncomplicated delivery 15 days previously. Her body mass index was in the normal range. The patient had marked distension …